Letter to the Editor: When a parent requests a vaccine exemption, what will you do?
Letters to the Editor
In response to resurgence of measles, several state legislatures are considering or
have enacted legislation to restrict or eliminate parents’ ability to get a personal,
philosophical or religious exemption to the state’s school or child care immunization
What will you do when you encounter a parent whose child has no medical contraindication
or even precaution to receiving measles, mumps, rubella (MMR) vaccine but adamantly
refuses the vaccine for the child? Perhaps the parent is fearful of potential adverse
consequences, such as autism.
It is important to remember that there are few valid medical contraindications to
MMR immunization. A parent who is fearful of potential adverse consequences is not
one of them. Nor is having a sibling who experienced a devastating adverse event in
temporal association with receiving MMR vaccine.
However, we also need to acknowledge that parents may be genuinely terrified and doing
what they believe is best for their child.
It can be difficult to administer MMR vaccine over a parent’s strong objection. It
can be tempting to find a way to rationalize signing a medical exemption. What will
Contraindications and precautions to MMR vaccine are a severe allergic reaction (e.g.,
anaphylaxis) after a previous dose or to a vaccine component; pregnancy; known severe
immunodeficiency (e.g., from hematologic and solid tumors, receipt of chemotherapy,
congenital immunodeficiency, long-term immunosuppressive therapy or patients with
HIV infection who are severely immunocompromised); and family history of altered immunocompetence,
according to the Advisory Committee on Immunization Practices of the Centers for Disease
Control and Prevention.
Precautions include recent (11 months or less) receipt of antibody-containing blood
product (specific interval depends on product); history of thrombocytopenia or thrombocytopenic
purpura; need for tuberculin skin testing or interferon-gamma release assay testing;
and moderate or severe acute illness with or without fever.
Note once again that a family history of an adverse event in temporal association
with an immunization is not listed.
What to do? We believe the prudent physician will respectfully 1) explain the child
has no medical contraindication to receiving MMR vaccine; 2) state that it is in the
child’s best interest to receive the vaccine; 3) note that the parent sincerely believes
he or she is acting in the best interest of the child and therefore you will not administer
the vaccine over the parent’s objection; and 4) state that you will not attest that
the child has a valid reason for a medical exemption.
Be empathetic. Try to engender trust. Partner with the parent. Yet, acknowledge to
the parent that failing to immunize the child against MMR will result in the child
being out of compliance with the law.
The parent and public health officials then must deal with the consequences of the
parent’s actions. This is appropriate as civil authority, not physicians, must balance
individual freedom of choice and protection of public health. The public health authority
may determine what if any degree of coercion is warranted to get the child in compliance
with state law or exclude the child from school or child care.
Physicians must maintain their professional integrity and attest only for valid medical
exemptions despite their compassion for the parent’s distress and the consequences
for the child.